Surgery for Shoulder Instability

Lennard Funk

Rugby Injury• 24 year old

• Semi-Pro Rugby player

• Tackling injury

• Unable to continue

• Mid-season

• Struggling with weights

• Unable to play at same level

Decision Making

1.Does he need surgery?

2.Why?

3.When?

4.How?

5.Recovery Times?

Factors:

1.What is the extent of injury?

2.Time of Season?

3.Return to play with/without surgery?

Bony BankartHAGL

SLAP

Rotator Cuff Tear

Reverse Bankart

Lesions

Major ‘Minor’• Bony Bankart• ALPSA• Rotator Cuff Tear• HAGL

• Undisplaced Labral Tear• Partial Cuff Tear• ACJ Dislocation

L Funk / 2002

Case ExampleAge & Sex: 22yr Male

Semi-Pro Rugby Player

1st Disloc: Rugby Tackle 6 months agorelocated in A&E

Recurrences: 3 recurrences with rugby in ABER relocated each time

Other: Keen to return to rugby, but unable

MR Arthrogram Bony Bankart lesion & HAGL

Traumatic

RecurrentAnterior

Dislocation

Large lesion RepairBony Reconstructions

Polar ITraumatic Structural

Direct

Complex Labral

Bony BankartPTCT

Flexed Fall

Posterior Labral

RHAGL

Try Scorer

BankartSLAP

Rotator Cuff

Tackler

BankartSLAPHAGL

Mechanisms of Injury

Clinical Exam: Instability in Athletes

• True Instability• Dislocation• Subluxation• Apprehension• Large lesions

• Subclinical Instability

• Dead Arm in ABER• Pain in ABER• Clunking• No Apprehension• Smaller lesions

Posterior

Modified O’Brien’s Test (MOB)Wrightington Posterior Instability Test (WPIT)

WPIT - Wrightington Posterior Instability TestOwen, Mackenzie, Boulter, Funk, 2014

MR Arthrogram v. Scope

Sensitivity Specificity Accuracy

SLAP 0.42 0.92 77%

Rotator Cuff Tear

0.50 0.86 83%

Hill Sachs 0.91 0.78 90%

Bankart 0.85 0.83 86%

Karson, Geoghan & Funk, SECEC 2011

Radiologist Locality

• MRA is not 100% sensitive or specific and does not negate arthroscopy.

• The accuracy of MRA to determine the location of a labral tear was low

• There is a lower diagnostic accuracy of posterior than anterior labral lesions

• Accuracy of glenohumeral MRA diagnosis is achieved with increased experience of radiologist within specialist units and regular surgical feedback of cases

• Negative scan results are not absolute and should not preclude investigation with arthroscopy

Karson, Geoghan & Funk, SECEC 2011

• An experienced Shoulder Surgeon better

• Can correlate with clinical context

• Experience of reviewing Scopes & Scans

• Early Surgery:

• Major structural lesions

• Late in Season

• Unable to Return

• Rehab & Return:

• Minor structural lesions

• Early season

Timing of Surgery

Types of Surgery

• Mostly Arthroscopic Direct Repairs

• Latarjet for High-Risk/Revision

Bankart Repair

Latarjet

• Anterior Instability

• Revision surgery (even without bone loss)

• Chronic Bony Bankart (> 3months)

• Any Bony Glenoid Loss

• True dislocation in Front Row forward (Rugby Union)

• Higher level of sports

Latarjet in Athletes

Safe Zone

Post-Op Rehab Phase and Sport specific - Not time based or ‘Accelerated’

Phase 1: (Level 1 Exercises)

Core stability & Scapula control

Proprioceptive exercises (minimal weightbearing below 90 degrees)

Active assisted ROM as comfortable (in 'safe zone' )

Do not force or stretch

No combined abduction & external rotation

Phase 2: (Level 2 Exercises)

Progress active assisted to active ROM as comfortable

Phase 3: (Level 3+ Exercises)

Regain scapula & glenohumeral stability working for shoulder joint control rather than range

Gradually Strengthen

Plyometrics and pertubation training

Creighton et al. CJSM 2010

Our Results

• Arthroscopic Soft-tissue Bankart’s only

• Primary Procedures

• January 2005 - January 2007

• 128 shoulders

• Return to Sport = 4.8 months

• Return to Sport at same level = 84%

• Recurrent Instability = 6% (7/128)

Rugby Results ‘03-’05

Pain Satisfaction (%) Playing at previous level

Pre-op 5 11% 0%

3 months 10 87% 89%

6 months 12 93% 94%

L Funk , K Roney, CJSM, 2007

Return to Play

Repair! Months-post.op!SLAP! 2.6!Ant.*&*SLAP! 3!Post.*&*SLAP! 4!Ant.*Post.*&*SLAP! 5.5!

L Funk , K Roney, CJSM, 2007

Atraumatic Instability

L Funk / 2002

CaseAge & Sex: 22yr Female

Gymnast

1st Disloc: Painful for 2 years Slipped out whilst training 1 year ago

Recurrences: Painful ‘slipping’ when training

Other: Unable to competeHas generalised hyperlaxity

MR Arthrogram Small, rounded antero-inferior labrum

Capacious capsule

(A)traumatic

Multidirectional

Recurrent

Subluxation

Polar IIAtraumatic Structural

Rehab +/-Capsular Plication

Rehab• Optimise:

• Core

• Scapula

• Kinetic Chain

• Psychology

Decision Making

IGHL Hammock

Capsular Plication

Thank You

Thank Youlenfunk@shoulderdoc.co.uk